EEG as a part of the decision-making process in the emergency department.

STUDY OBJECTIVE: Although electroencephalography (EEG) is a useful diagnostic tool for patients with a suspected seizure, its value in informing the acute care of patients in the emergency department (ED) remains unclear. The aim of this study is to determine the effects of EEG results on subsequent patient management in or from the ED. MATERIALS AND METHODS: This prospective observational study was carried out in the ED of a tertiary-care university hospital. All patients presenting to the ED with seizure or seizure-mimicking symptoms were included in the study. EEG was advised for all patients after an initial evaluation. Before EEG, the ED physician and neurologist were asked clinical questions about the patient. The consistency between the clinical decision of emergency physicians before the EEG report and the final management of patients determined by the consultant neurologist was analyzed. The interobserver reliability of the physicians was determined. RESULTS: Overall, 110 patients were enrolled in the study. The sensitivity and specificity of ED physicians' diagnosis of the presence of seizure were both 88% (95% confidence interval, 79-93 and 62-97%). The interobserver reliabilities and κ values of ED physicians and neurologists were found to be 'moderate'. Patients with abnormal EEG results were prescribed new medication (P=0.003) and changes in therapy (P=0.59) were more than for patients with normal results. CONCLUSION: As seizure is a clinical event, EEG is not essential for diagnosing the presence of a seizure clinically in the ED. However, the results of EEG provide useful information especially for treatment choices. As the timing of the study affects the diagnostic efficacy of the test, EEG recordings should be performed within 24 h either in ED or in the epilepsy clinic.

The utility of EEG in the emergency department.

BACKGROUND AND AIM: Seizure-related visits are common in the emergency department (ED) but the clinical situations for ordering emergency electroencephalography (EEG) are unclear. The aim of this study is to identify which clinical conditions meet with the pathological EEG and whether patient management is changed by abnormal results. METHODS: A retrospective chart review study of all patients visiting the ED with a seizure or symptoms mimicking a seizure was performed. Patients who recorded an EEG within 16 h after the initial event were enrolled. Demographic data and EEG results of patients with provoked and unprovoked seizures were recorded and related factors were analysed. RESULTS: A total of 449 patients (219 men) of mean ± SD age of 45.48 ± 21.83 years were evaluated. The seizure was thought to be provoked in 98 patients (21.8%) and unprovoked in 352 (78.2%) patients (31.2% remote symptomatic and 47.4% idiopathic). The EEG results of 281 patients (62.6%) revealed an abnormality, and the abnormal EEG ratio was high in patients with presumed seizure (p<0.001). One hundred and thirty-eight patients (30.7%) were hospitalised and the remainder (n=311, 69.3%) were discharged from the ED. An abnormal EEG was found in 98 (71%) of the hospitalised patients and in 183 (59.5%) of those discharged (p=0.019). CONCLUSION: EEG provides useful diagnostic information and should be considered in all patients presenting to the ED with a seizure. Since the timing of the study affects the diagnostic efficacy of the test, EEG recordings might be done within 24 h either in the ED or epilepsy clinic.

VEGF polymorphisms and serum VEGF levels in Parkinson's disease.

Accumulated data within the recent years demonstrate that reduced levels of VEGF which is a well known angiogenic molecule might cause neurodegeneration in part by impairing neural tissue perfusion, vasoregulation and normal functioning of perivascular autonomic nerves. Additionally, VEGF has been reported to support neuroprotection in dopaminergic neurons by indirect and direct mechanisms and suppress apoptosis in dopaminergic neurons in vitro. The aim of the current study is first to demonstrate whether there is an association between the three common VEGF polymorphisms (-2578C/A, -634C/G and 936C/T) in the VEGF gene and idiopathic Parkinson's disease (IPD) which is a neurodegenerative disease caused by the progressive degeneration of nigrostriatal dopaminergic neurons, and second to see if the serum levels of VEGF is reduced in the patients with IPD. We screened the genotype and allele frequencies of three common functional polymorphisms of VEGF, namely -2578C/A, -634C/G and 936C/T in DNA samples of 126 patients with IPD and healthy control subjects and also we compared the median serum levels of VEGF between these two groups. No association was found between the inspected VEGF polymorphisms and IPD and also no difference was found between the serum VEGF levels of both groups. The current study failed to support the hypothesis that VEGF polymorphisms and/or reduced serum VEGF levels are likely contributors to the neurodegenerative process in IPD.

Transcranial Doppler ultrasonographic evaluation of cerebral circulation during passive tilting in patients with Parkinson's disease.

PURPOSE: To assess the effects of the tilt test on cerebral blood flow velocity (CBFV), blood pressure, and heart rate in patients with Parkinson's disease (PD) without symptomatic orthostatic dysautonomia. METHODS: Thirty patients with idiopathic PD and 15 healthy controls were included. Mean middle cerebral artery blood flow velocity (CBFV) was recorded with transcranial Doppler sonography, while systolic (SBP), diastolic (DBP), and mean (MBP) blood pressure and heart rate were measured in the supine position and after passive tilting. RESULTS: There was no difference in resting SBP, DBP, or MBP between patients and controls. CBFV was lower at rest in patients than in controls and dropped significantly and similarly after tilting in both groups. SBP decreased in patients during the first 5 minutes of tilting (p < 0.05), whereas it increased progressively after the first minute in controls. In patients, DBP decreased slightly and MBP dropped during the first 2 minutes, then increased. Baseline heart rate was higher in patients than in controls (p < 0.05) and increased in both groups during tilting. CONCLUSION: Our results suggest that cardiovascular responses to tilting are delayed in PD patients and that subclinical autonomic dysfunction may be present even in the absence of symptomatic orthostatic dysautonomia.

Enhanced cued recall has a high utility as a screening test in the diagnosis of Alzheimer's disease and mild cognitive impairment in Turkish people.

Enhanced cued recall (ECR) is highly sensitive and specific in discrimination of demented from non-demented elderly persons. The nature of the test promises that it can be applicable to subjects in different cultures and education level. We studied the utility of the test in a Turkish population. Eighty consecutive cases with dementia or mild cognitive impairment (MCI) and 33 elderly controls were studied. The utility of ECR was high in discriminating dementia from controls (area under curve (AUC)) of the ROC curve: 0.907 (95% confidence interval (CI): 0.830-0.953 for total recall), Alzheimer's disease from controls (AUC: 0.990 (95%CI: 0.934-0.998 for total recall)) and moderate (AUC: 0.625 (95%CI: 0.545-0.812 for third free recall)) in discriminating MCI from controls. Education did not affect the utility of the test. We conclude that ECR is a valuable test in assessment of elderly Turkish patients with a complaint of memory impairment.

Prolonged hyperglycemia in the early subacute period after cerebral infarction: effects on short term prognosis.

Although the adverse effect of admission hyperglycemia in cerebral infarction on prognosis is well known, studies generally have not questioned the effect of hyperglycemia in the early subacute period on prognosis after a stroke. Forty-six patients with acute ischemic stroke were seperated into 3 groups: Group 1) Known diabetes or admission blood glucose (ABG) > or = 140 mg/dl and HbA1c > or = 8,0%); Group 2) ABG > or = 140 mg/dl and HbA1c < 8,0%; and Group 3) ABG < 140 mg/dl and HbA1c < 8,0%. Blood glucose was followed-up 4 times a day for 10 days after the stroke and the mean of these measurements was calculated as the mean of glycemic regulation (MGR). Neurological evaluation was done at presentation and on day 10 and 30 with the National Institute of Health (NIH) scale. Oedema, lesion size and presence of hemorrhagic transformation were evaluated using CT. The MGR was significantly higher in group 1 compared to the other two groups (p < 0,001 and p < 0,01) and in group 2 compared to group 3 (p < 0,001). Patients with clinical worsening had a significantly higher MGR (p < 0,05). Patients with marked cerebral edema had a significantly higher MGR (p < 0,01) compared to patients with lesser edema. No correlation was found between MGR and lesion size or hemorrhagic transformation. Our results show that hyperglycemia in the early subacute period after cerebral infarction is associated with more pronounced cerebral edema and has an adverse effect on short term prognosis. We suggest that studies investigating the effect of insulin infusion on stroke prognosis should also consider infusions for a longer period than 24 hours.

Effect of donepezil on EEG spectral analysis in Alzheimer's disease.

EEG spectral analysis allows a quantitative analysis of changes in the frequency bands during disease progression in Alzheimer's disease (AD) and could be used to monitor treatment and disease progression. Eighteen patients with probable AD were evaluated by Folstein Mini Mental State Examination (MMSE) and EEG spectral analysis before donepezil treatment, 2 months after 5 mg/day and 4 months after the dose was raised to 10 mg/day. EEG evaluations were done in 4 derivations (T3-T5, T4-T6, C3-P3, C4-P4). Six months after treatment there was a significant reduction in the temporal delta amplitudes and an increase in the amplitudes of all the other frequency ranges including theta amplitudes both in the temporal and centroparietal derivations. MMSE scores increased during treatment but the change was not significant. These findings show that donepezil exerts a positive effect on EEG in AD by decreasing delta activity and increasing alpha and beta activity. The increase in theta activity after treatment may reflect a therapeutic shift of delta activity to theta activity.